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|DOCUMENTATION OF PNP EDUCATION FORM |

|PEDIATRIC NURSING CERTIFICATION BOARD |

|9605 Medical Center Drive, Suite 250 |

|Rockville, MD 20850 |

|1-888-641-2767 - |

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|The PNP exam applicant must be a graduate of an accredited college or university that offers an NLNAC or CCNE accredited formal nursing |

|master’s or doctoral degree program with a concentration in pediatric primary care, acute care or dual primary/acute care as a nurse |

|practitioner. The PNP exam applicant may also be a graduate of a formal post master’s pediatric primary care or acute care nurse practitioner |

|certificate program from an accredited college or university. All information below must be provided. Blank items will invalidate this form. |

|This form must be completed and signed by a Program Director or appropriate designee in order for the form to be valid. Electronic signatures |

|are acceptable. The completed form must be emailed from the program director directly to exam@ or faxed to 301-330-1504. |

|APPLICANT Information (Complete through #6 below then forward to your PNP Program Director) |

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|Applicant Name (First, Middle, Last): |

|Last 4 digits of Social Security Number: |

|Email Address: |

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|Dual track PNP Primary Care and PNP Acute Care students must document completion of each PNP clinical track. One form will provide |

|verification for both tracks. |

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|1. Please select the appropriate PNP Exam |

|Primary Care PNP Exam Acute Care PNP Exam |

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|2. Please select the appropriate educational track and enter the degree conferral date. |

|Master’s (MM/DD/YYYY) |

|Post Master’s (MM/DD/YYYY) |

|DNP/Doctoral student(MM/DD/YYYY) |

|Program Information |

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|3. Name of School |

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|4. Name of Program |

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|5. Address of School |

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|PROGRAM DIRECTOR (Complete the Below Information using the accreditation dates at the time the student attended the program.) |

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|6. Accreditation CCNE NLNAC Both |

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|Accreditation Date (MM/YYYY) |

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|Expiration Date (MM/YYYY) |

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|7. Total number of clinical hours       |

|(The National Task Force Criteria for Evaluation of Nurse Practitioner Programs requires a minimum of 500 supervised clinical hours per program|

|track. PNCB highly recommends 600 supervised clinical hours for acute care programs.) |

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|8. Dual Primary/Acute Care PNP Program (Check if Yes) |

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|9. Complete information for the following courses – if student completed a dual program please complete the course information for both |

|the acute and primary care tracks. |

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|Course Name |

|Course Number |

|Course Title |

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|Advanced Physiology & |

|Pathophysiology |

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|Advanced Pharmacology |

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|Advanced Health Assessment |

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|Signature of Program Director:       |

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|Title       |

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|Phone Number:       |

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|Email Address: |

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|Date (MM/DD/YYYY)       |

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|This Documentation of PNP Education Form must be submitted directly to the PNCB from the educational institution. |

|Please email this form to exam@ or fax to 301-330-1504. |

|Revised 4/22/2015 |

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